acoustic neuroma… all in the family

ACOUSTIC NEUROMA…
ALL IN THE FAMILY
Volume 5, Number 1
IRSA
The Publication for the International Radiosurgery Support Association
another perspective
TM
ISSN 1086-427X
Marjie and Jeff each had an acoustic neuroma. We thank them for sharing their courageous story with us.
Marjie:
This is a story about coincidence and
determination. It is a wonderful story for the
International Radiosurgery Support
Association because it contains all the points
of concern that we each face during our unsettling trip through the decisions surrounding
how to treat brain tumors.
It begins with me, Marjie, when I started
having hearing problems in late 1994. In
December of that year I was diagnosed with
an acoustic neuroma and began my search for
the “right” solution to my problem. In 1994
the medical profession in Columbus, Ohio
firmly believed in
surgery as the only reasonable treatment for
brain tumors, even
benign ones such as an
acoustic neuroma. My
initial search brought me
to the “best” and “most
knowledgeable” otolangologist in the city
who told me surgery was considered the treatment of choice. I initially thought this was
my only option but had concerns after learning about potential post-operative problems.
Although each negative outcome represented
a small probability, to me the cumulative
effect of the problems was too high to ignore.
In addition, I still had 94 percent hearing in
my right ear and no noticeable balance problems. Surgery did not appear to be the way to
ensure the preservation of my hearing and
balance.
My husband, Jeff, and I began to investigate the available alternatives. Some of our
friends were very knowledgeable about ways
to use the Internet (even in 1994) and they
helped me discover the Gamma Knife. Since
Jeff and Marjie
Gamma Knife radiosurgery was not offered in
Ohio and much of the current research came
from The University of Pittsburgh, I chose to
consult with Dr. Dade Lunsford at
Presbyterian Hospital, part of The University
of Pittsburgh. My procedure was performed
on the morning of January 3, 1995. My
recovery was immediate with no side effects.
Five years have passed and I have had a
very positive result. My hearing was
maintained over the first four years, although
I have experienced a slight decline recently. I
now wear a “state of the art,” almost invisible,
digital, programmable hearing aid by Sonnic
Innovations called Natura. Radiosurgery had
no affect on my balance and trigeminal
nerves. My 2.3 centimeter tumor has stopped
growing and has begun to shrink. My experience has been so positive that I have shared
it with others on the Internet and on television. Five years passed and the acoustic
neuroma was no longer part of my daily
conscious thought.
Continued on page 11
FEATURES
Difficult Tumors .......................2-4
New MRI’s ...................................7
Medical Records ..........................8
PATIENT STORIES
Acoustic Neuroma........................1
Glioblastoma ................................5
AVM.............................................8
Stereotactic
Radiosurgery
S
tereotactic radiosurgery is not surgery.
The skull is never opened. Radiosurgery
involves the use of precisely directed single fractions of radiation to create lesions
within the brain or to treat tumors or vascular malformations with minimal damage to surrounding structures or tissues.
This works by delivering a relatively
high dose of radiation in one session to
the target with scalpel-like precision. The
dose is designed to injure or kill the cells
or their supporting blood vessels, while
minimizing its effect on surrounding
healthy tissue. The radiation distorts the
cells’ DNA, causing them to lose the ability to replicate themselves. The safety and
clinical effectiveness of this technique
has been established since 1968 in over
150,000 treated individuals.
The benefits include: No risks of
infection or anesthesia reactions; virtually
no pain; reduced costs; and an immediate
return to normal activities.
Radiosurgery may or may not be
appropriate for your condition. It may be
used as the primary treatment or recommended in addition to other treatments
you may need. Only a treating neurosurgeon can make the evaluation as to
whether you can be treated. Some of the
most common indications for treatment
today are:
• Arteriovenous/vascular malformations
• Meningiomas
• Acoustic neuromas
• Pituitary and pineal tumors
• Metastatic tumors
• Glial and astrocytoma tumors
• All other malignant & benign tumors
• Trigeminal neuralgia
• Parkinson’s tremors/rigidity
• Functional disorders
Stereotactic Radiosurgery for
Difficult and Dangerous Tumors
The field of stereotactic radiosurgery has evolved markedly over
the decades. In the past we treated simple, spherical pathologies
with a simple solitary shot of radiation. Now with increased experience, and improved planning software and technology, we are
boldly tackling complex, large, irregularly shaped masses that
were once thought to be untreatable.
The successful use of this technology for treating small tumors
in dangerous locations has blossomed to near perfection. Recurrent tumors in the
pediatric population are now being treated with stereotactic radiosurgery, allowing a
young child to avoid a second or third craniotomy. All this has prompted the evolution
of a “new era” of radiosurgery.
The radiosurgeon is often faced with a patient who has had multiple open surgeries,
saddening complications and a recurrent tumor. I have seen many young children, for
example, who have had two or three craniotomies to remove a tumor which is just
impossible to remove. Had these patients been seen by the radiosurgeon with a new
MRI scan immediately after the initial operation, perhaps they could have been treated
and potentially cured with radiosurgery. The problem lies in a relative misunderstanding of the potential of radiosurgery on the part of patients, families and referring physicians.
In the four cases presented on pages 3 and 4, radiosurgery was furthest from the
minds of the original treating physicians. The family members did their due diligence
in researching their loved ones’ options and often they themselves served as the referral source. Misunderstandings such as “the tumor is too large,” “it is near very critical
structures,” or “its shape is too complex to treat” are simply the words of physicians
inexperienced with the technique and results of radiosurgery. Only an experienced
radiosurgeon is able to make those judgements.
The “new era” of radiosurgery is now upon us. We can now treat pathologies
which were once thought untreatable. As we move into the new millennium more and
more patients will be helped with stereotactic radiosurgery.
Dr. Christopher Duma is the Medical Director of Hoag/UCI Gamma Knife Center at Hoag
Hospital in Newport Beach, California. He can be reached by phone at +949-574-6232, and
through e- mail at cduma @hoaghospital.org.
Disclaimer
All technical information regarding
any technology published by IRSA, in
this publication or elsewhere, has been
provided by the manufacturer of the
equipment. The publisher does not warrant any instrument or equipment nor
make any representations concerning its
fitness for use in any particular instance
nor any other warranties whatsoever.
Dr. Christopher Duma
2
Another Perspective, Volume 5, Number 1
Craniopharyngioma – Case Number 1
Case number one is a 38-year-old
male who was in good health until severe
headaches, nausea and vomiting, and
visual changes led to an MRI. This
revealed a large suprasellar cystic mass
and obstructive hydrocephalus. He
underwent temporary ventriculostomy
and a frontal craniotomy for removal of a
craniopharyngioma (a remnant of
embryogenesis in the pituitary region).
He did well postoperatively and required
total pituitary replacement therapy.
Months later, the tumor was back, again
compressing his optic nerves. The
patient refused to have another operation
and sought Gamma Knife radiosurgery.
A complex treatment plan, with
“plugging” of certain collimator holes in
order to keep the dose of radiation away
from the optic nerves, was administered
using the Gamma Knife. As you can see
from the images above the tumor began
shrinking within two months and by one
year, the tumor was gone. The patient
avoided a second craniotomy, which
invariably would have resulted in yet
another incomplete resection, and he is
currently in perfect post-Gamma Knife
condition.
Astrocytoma – Case Number 2
The patient is a very bright, alert
and intelligent 10-year-old young lady,
who at age two underwent a biopsy of a
hypothalamic lesion. This was considered an astrocytoma at the time (a low
grade, benign tumor). She underwent 18
months of chemotherapy and radiation
therapy. She did well until the tumor
began to grow again, changing from two
cm in diameter to about three cm in
diameter over six months. Even an inexperienced viewer can see from the
images shown here that the tumor in this
bright, intelligent and fully functional
patient is not resectable by surgical
techniques. She underwent Gamma
Knife radiosurgery with a complex 11shot plan with tight margins, and on the
seven-month follow-up there are already
signs of shrinkage and necrosis of the
tumor. She is doing great.
Continued on page 4
Another Perspective, Volume 5, Number 1
3
Gliosarcoma – Case Number 3
A bright nine-year-old boy presented
with symptoms of elevated intracranial
pressure and gait disturbance and failure
to thrive in March of 1995. The original
surgery was aborted by the surgeon
because the tumor felt “like a piece of
wood.” In a second operation two years
later, the surgeon was only able to perform a biopsy. He underwent 14 months
of chemotherapy but no XRT (external
beam radiation therapy). After a third
craniotomy with similar dismal results,
the patient was referred by his pediatric
neurosurgeon who felt that the tumor
might be managed with Gamma Knife.
In March 1999 the patient underwent a
complex Gamma Knife treatment involving multiple isocenters for precise conformal planning. His nearly one- year
follow-up MRI images are seen below,
with a near miraculous result. Had it not
been for the educated referring neurosurgeon the child would not have made it to
radiosurgical treatment.
Brainstem Glioma – Case Number 4
A lot has been said about the deadly
brainstem gliomas. Open craniotomy for
these tumors can be performed if the
tumor does not completely involve the
brainstem, but it is never enough.
Because of the involvement of the important brainstem, average life expectancy is
on the order of only a few months. We
have now treated a number of patients
with both low grade astrocytomas and
anaplastic and the higher grade astrocytomas with astounding results. Figure 4 is
an eight-month follow-up of a 10-year-old
boy treated with surgery and Gamma
Knife radiosurgery. He is currently
steroid-dependent, but his tumor is shrinking. This is one of the first times this has
been attempted, and the results are
promising.
4
Another Perspective, Volume 5, Number 1
GLIOBLASTOMA - 10 YEARS LATER
Editor ’s Note: The diagnosis of
Glioblastoma Multiform has always been
considered a death sentence. Patients
are routinely told that they have six to
twelve months to live. However, as
Charlie has found out, after the initial
treatments and the side effects, life does
go on. Charlie and Joanne aggressively
sought all treatment modalities, surgery,
chemotherapy, radiation therapy and
radiosurgery with the Gamma Knife.
Research is now suggesting that those
whose diagnosis is timely and who
receive adjunct treatments, may survive
with quality of life and minimal effects.
We believe that the ‘spirit’ of Charlie and
Joanne has also promoted his well being.
Charlie and Joanne have learned to
overcome the difficulties and to move on
with life. We are pleased to update their
story for those of you who have repeatedly wanted to know how they are doing.
Charlie is a familiar sight around his
neighborhood
in
Marmora, New Jersey,
USA. Riding his electric scooter with his
golden retriever companion dog at his side,
he runs errands and does
chores around the house.
This 61-year-old former administrator
is no quitter. Not even the “tumor
stroke” could stop him.
Sometime in 1990, Charlie started
experiencing focal seizures in his right
arm. “It would take on a life of its own,
flailing,” says his wife, Joannne.
Charlie worked as a school monitor
for the New Jersey Department of
Education and was involved in rating
school districts. He drove 75 miles from
his home to his office in the morning and
75 miles back in the evening. He started
having seizures in his right arm during
his commute.
“I would just get over to the side of
the road and stop and wait till it passed,”
Charlie recalls. “It was a pain in the
neck. It was scary.”
“We thought it was a muscular thing,”
says Joanne. “His cousin, a nurse, recommended a neurologist.” This doctor
thought Charlie had meningioma, a
benign tumor on the protective coverings
of the brain. “The neurologist said 90
percent of the time, it’s benign and in a
little sac and they pop them out,” Joanne
says.
Charlie had a craniotomy in early
Charlie and his dog.
1991. Instead of a meningioma, doctors
found a glioblastoma - fast-growing,
highly malignant brain tumor - on the
left side of his cerebral cortex. It was
3.5 to 4 centimeters in size and had tentacles.
“They did a biopsy, sewed him back
up (with more than 100 stitches) and
recommended radiation,” Joanne says.
“It pretty much had a negative prognosis. Radiation was a shot in the dark.
They were hoping that would stall the
(tumor’s) growth.”
After seven weeks of radiation treatment, Charlie’s glioblastoma shrank to 2
cms.
“Right after the surgery, he had a lot
of seizures but they stopped within a
month,” Joanne says. “He was on medication and he kept working through this.
My husband has an extremely positive
attitude.”
When New Jersey offered an early
retirement program that year, Charlie
took it.
By January 1992, a year after the
cranitotomy, Charlie started to suffer
seizures again and his right arm and leg
were weak. By June, he couldn’t use
them. MRIs showed the tumor was
growing.
Their doctors had given them no
hope, Joanne says. They had not even
arranged physical therapy for Charlie.
“With prayers to God, we were led to the
right doctors,” she says.
Continued on page 6
Another Perspective, Volume 5, Number 1
5
Glioblastoma
Continued from page 5
They went to the University of
Pittsburgh Medical Center in October
1992. With his right side paralyzed,
Charlie was in a wheelchair. Dr.
Douglas Kondziolka, stereotactic neurosurgeon at Pittsburgh, asked Charlie,
“What do you want us to do?” Charlie
said he just wanted to “live as normal a
life as possible.” Dr. Kondziolka said
this was also his goal.
Doctors at Pittsburgh found that
Charlie had 4 cms of scar tissue from the
brain surgery. They recommended
experimental chemotherapy treatment BCNU and Cisplatin delivered intravenously continuously for three days beginning in January 1993. The couple
spent one week a month in Pittsburgh for
four straight months. Today, Joanne
jokes about how they spent the early
1993 holidays in the Steel City - their
anniversary in January, Valentine’s Day
in February, St. Patrick’s Day in March
and Easter in April.
Each time, Charlie received
chemotherapy for 72 hours at Pittsburgh
Cancer Institute. “We’re 10 hours from
Pittsburgh (driving time) so we would
fly there,” Joanne says. “Then he would
need a couple of days to get back on his
feet” before they could fly back to New
Jersey.
The experience was “unbelievable,”
Charlie says. He used meditation, which
he taught himself, to make it through the
treatment. “It works,” he says.
While he was being treated, Joanne
stayed at a Family House facility. This
non-profit organization provides an inexpensive “home away from home” for
patients with life-threatening illnesses
and their families. Joanne praises the
program and its volunteers. “They are
life savers for anyone who has to travel
from a distance to Pittsburgh for treatments.”
The goal of the chemotherapy was to
shrink Charlie’s tumor down enough for
the Gamma Knife.
“He usually had one day of upset
stomach afterward but they gave him a
lot of medication to combat that,”
Joanne recalls. “By the second week at
home, he was feeling weak and tired,”
but still kept up with his physical
therapy. “By the time he was feeling
well again, it was time to go back to
Pittsburgh” for the next round of chemo.
In the meantime, a visiting nurse saw
Charlie three times a week. He was on
6
Another Perspective, Volume 5, Number 1
“all kinds of minerals and vitamins.”
“God was with us,” Joanne believes.
“He was injecting strength into us each
time.”
At the end of the third session,
Charlie says he knew the treatment had
worked. His body felt different and “I
had a feeling that it was over.”
In April, tests showed the experimental chemotherapy had indeed done its
job: Charlie’s tumor had shrunk enough
that he could have the Gamma Knife.
He was treated in May 1993.
Since then, MRIs have shown no significant growth in Charlies’ glioblastoma. He has the MRI done near his
home in New Jersey and it’s sent immediately to Pittsburgh.
“Dr. Kondziolka and his staff have
been always kind, caring and extremely
sensitive to our needs through all these
years,” Joanne says. “They truly are a
class act,” and continue to follow
Charlie even now 10 years later.
His right side is still partially paralyzed, but Charlie uses a partial walker
and his electric scooter to get around.
He continues to work in physical therapy
to keep his right side active, moving and
in good shape.
Besides physical therapy, Charlie
“If at first the idea
is not absurd,
then there is
no hope for it.”
– Albert Einstein
works on exercises to assist his memory
in recalling letters and numbers.
“You have to keep working on it and
the skills return,” Joanne says. “He reads
a lot. But writing is a problem.”
Charlie’s speech was also affected.
He can formulate ideas in his mind but
can’t always express them, or the words
come out backwards.
“It’s very frustrating because he
knows what his mouth wants to say but
he can’t always say it,” Joanne says.
Despite his physical problems, she
says, “he has good quality of life.”
When he can, Charlie works three days a
week for their county diagnostic training
center. “It’s a boost to his morale,”
Joanne says. The center provides
employment opportunities for people
with disabilities.
In late1998, Charlie needed dental
surgery. His physician recommended a
quick hospitalization to prevent problems. However, Charlie contracted an
infection, and then developed blood clots
in his leg and had to have a vascular
bypass surgery on his leg. After the
surgery, Charlie was admitted to a rehab
facility for five months to regain the use
of his leg. Complications continued
when he had to deal with a pressure
wound from the knee stabilizer he was
required to wear. Through all of this
Joanne says that Charlie maintained a
good attitude and a great sense of humor.
It was especially hard on her when
Charlie was not at home.
Charlie’s constant companion, his
golden retriever, Heather, had to be ‘put
down’ as she was found to have had cancer throughout her body. This was especially hard for the McGuires. They now
have a new golden retriever named
‘Sweet Dreams’ which they lovingly call
‘Sweety.’ Sweety roams the neighborhood everyday with Charlie who uses his
scooter. Joanne states that Sweety is
quite a hand full at a year and a half of
age and is very playful.
Prior to 1990, Charlie was very active
in his church and the community. He
served as an emergency medical technician and was in the National Guard. So
tumor or no tumor, “he was absolutely
determined to get out,” Joanne says.
“Everybody in our town knows him.
He goes everywhere with the scooter and
the dog.”
Charlie adds: “It’s a nice feeling. The
neighbors are a big help.”
He still does what he can, raking
leaves and taking out the garbage onehanded.
Charlie and Joanne go out to eat, have
friends over and travel to Florida on
vacation. They have two grown children: Jeff, 34 and Julie 28.
“It’s a good life,” Charlie says. “I’ve
been lucky to have Joanne.”
For her part, Joanne says, “He’s a
more positive person than I have ever
been so I’ve learned a lot from him. We
don’t look at this negatively at all. There
are no pity parties here.
The Evolving Role of Magnetic Resonance Imaging in Brain Tumors
Magnetic resonance imaging (MRI or
MR), in contrast to other types of imaging modalities for brain tumors (PET
scans, CT scans and angiography), utilizes no ionizing radiation to acquire the
data for the images. Instead, MR utilizes
magnetic fields and radio frequencies
(radio waves). Tissues in the body are
composed of a large portion of water.
One of the building
blocks of water is an
element
called
hydrogen, and the
nuclei (or centers) of
hydrogen contain
protons. Normally
protons are in constant motion and randomly aligned.
When a magnetic field is applied, the
protons all align and spin in the same
direction. When radio waves are then
applied, they knock these protons out of
alignment. Once the radio waves are
turned off, the protons realign themselves and emit radio signals. The radio
signals are then transformed by a computer into an image. MR can create an
image in all three dimensions.
Magnetic strength is measured in
units called “Teslas.” Routine clinical
MR units utilize a magnetic strength of
1.5 Tesla. The Ohio State University
Medical Center / Arthur James Cancer
Hospital and Richard Solove Research
Institute have constructed an ultra high
field MR for clinical use with a strength
of eight Tesla. A 4.2 Tesla unit is operational at Columbia University and a
seven Tesla MR is under development at
the University of Minnesota. With these
high field MR units, more detail of the
brain is possible. A temporary side
effect of being imaged at these high
strengths is vertigo (dizziness). It is
caused by stimulation of the inner ear
Dr. Kangarlu and Dr. Grecula
with motion and ceases after being
removed from the magnet.
The first clinical application of this
magnet at Ohio State will be the imaging
of the most aggressive brain tumor,
glioblastoma multiforme, before and
after administration of a radiosensitizer
called
Gadolinium
Texaphyrin
(Pharmacyclics Inc., Sunnyvale CA).
This type of tumor can be difficult to
image completely with lower Tesla units.
The patient will receive the radiosensitizer three hours prior to a Gamma Knife
radiosurgery boost (after five weeks of
conventional radiotherapy). The
patient’s tumor must be four cm in
greatest dimension and must be one cm
from the optic chiasm and brainstem. If
the tumor becomes four cm after
debulking surgery, the patient is still eligible for the study. Additional information regarding the Gadolinium
Texaphyrin trial, which is sponsored by
the National Cancer
Institute, can be
obtained by calling
1-614-293-4562.
This high strength
magnet will also be
utilized to image
patients with multiple
sclerosis.
Another area of
investigation in magnetic
resonance
imaging is called
functional
MRI.
Functional MRI can
be performed with a
1.5 Tesla unit. Signal changes are
detected by alterations in local blood
oxygenation levels. Some accomplishments of functional MRI include mapping areas of the brain responsible for
finger and thumb movements, receptive
language, and tinnitus (perception of
sound in the absence of external stimuli).
Dr. John C. Grecula is Assistant Professor
of Radiology, College of Medicine, Arthur G.
James Cancer Hospital and Research
Institute at the The Ohio State University. He
can be reached by phone at +614-293-8415
and by e-mail at [email protected].
Fast Facts
Radiosurgery offers many advantages including:
Requires no overnight hospital
stay or one-day stay.
Fewer side effects than conventional brain surgery.
No risk of bleeding or infection
and general anesthesia is not necessary.
Results in little or no pain.
Offers a rapid return to normal
activities without physical therapy or other rehabilitation.
Is covered by insurance companies and Medicare.
Cross sectional “eight-tesla” image of brain.
Another Perspective, Volume 5, Number 1
7
Your Medical Records…
The Association assists patients with
insurance denials by writing to insurance
companies, working with the insurance utilization review contact person and the medical director.
We provide up-to-date research, contact
neurosurgeons and act as a liaison where
needed between the insurance company, your
treating site and you. However, you as the
patient play an important part when it comes
to obtaining insurance approval for treatment.
Maintaining control of your medical
records and their contents is important in
securing further treatment approvals. Medical
records are also utilized for employment criteria and life and disability insurance
approvals. Denials of insurance coverage for
Canadian and United States citizens are
maintained on a national data base with the
Medical Information Bureau (MIB). This is a
data base established in 1902 by physicians
to detect fraud when someone applies for life,
or disability insurance. The MIB keeps a
record of up to seven years history of any
medical condition significant to health or
longevity.
Additionally, a record of some non-medical conditions such as an adverse driving
record or participation in hazardous sports
are maintained.
Doctor ’s records may be erroneous,
incomplete or both. In any case, however,
they are still the only “record” of what has
transpired. A more accurate rendition of what
goes on in the medical setting should be kept
by patients themselves. Patients need to be in
control of their medical records. Physicians
are busy, distracted and sometimes do not
know what an insurance company is looking
for.
To maintain your own records, you can
begin by taking notes when you visit your
doctors and asking for copies of each clinic
visit record generated by the doctor. All documents should be reviewed for accuracy and
completeness. Patients can request that more
information be added to their record or corrections be made if they note anything missing or incomplete. Always make sure your
physical condition and problem were
described completely at each visit. Insurance
companies look for full descriptions of how a
condition affects you, how long it has been a
problem and what non-surgical interventions
were tried.
You can be a powerful force in decisions
made about your medical care. Accurate
records may establish medical necessity
when a physician may be reluctant to declare
it. Well maintained records serve to increase
the likelihood of the medical consumer prevailing in a dispute with the doctor or insurance company.
If you are having problems with insurance
approvals, you should review your medical
records yourself. Ask for information to be
modified or added to the record if needed.
Also, consider requesting your record from
MIB (for a small fee) and request any corrections that may be needed.
To request your MIB records:
In USA:
MIB, PO. Box 105, Essex Station,
Boston, MA 02112, or
phone 1-617-420-3660.
In Canada: MIB, 330 University Avenue, Toronto,
Ontario, Canada M5G 1R7, or
phone 1-416-597-0590.
AVM - 10 Years Later
Editor’s Note: We first wrote about Kevin in
1998. His story has helped many parents in
similar situations. We are publishing Kevin’s
story again with updates for those who keep
asking about Kevin.
Beth and Dave of
Pennsylvania, USA,
have two sons - Eric,
17, and Kevin, who
just turned 14 on
March 21, 2000.
Both parents work
at Latrobe Area
Hospital, where Beth
is a nurse and David is a mental health
aide.
Their lives “changed dramatically” on
July 18, 1990, when a large arteriovenous malformation (AVM) that Kevin
apparently has had since birth suddenly
manifested itself.
As Beth relates, the two boys, then 7
and 4, were playing in the living room
while she was working in the kitchen.
She was trying to finish her chores so
8
Another Perspective, Volume 5, Number 1
she could take her sons to a summer fair
in town later that day.
“Kevin came to me and said he had a
headache,” Beth recalls. “I didn’t think
much of it, although he had never complained of a headache before. I told him
it would go away and to just go lie
down.
“He started to cry and said it really
really hurt, so I gave him some children’s Tylenol and told him to lie down
on the couch.” A little later, she went
into the living room to check on him.
Kevin said his head hurt terribly and
asked his mother if she could lie down
too and comfort him. In the years since,
Beth says, she has regretted telling him
then that she was too busy.
“Before long, he started crying again
with the pain in his head,” she says. “I
thought he was just cranky as it was such
a hot day.”
She took Kevin to his air-conditioned
bedroom so he could rest there.
“I was feeling very uneasy about him
and asked his brother, Eric, to go and
check on him while I made them some
Kool-aid,” Beth relates. “The next thing
I heard was Eric coming down the hall
shouting. ‘Emergency! Emergency!
Kevin threw up!’ I ran back to his room
and found him only responsive to painful
stimuli.”
As a nurse, she immediately realized
that something had increased the
intracranial pressure in Kevin’s brain.
She told Eric to run outside and get
Dave, who was working in the garden.
Dave picked Kevin up and started to
shake the boy in an attempt to wake him
up. Beth told him to stop. She suspected Kevin was bleeding inside his head.
Since the family lives only about one
mile from a hospital, they decided to
drive Kevin there instead of waiting for
an ambulance.
A CAT scan at the hospital revealed
Continued on page 10
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Have You Peeked?
We are up and running – with more to be done. Send your comments and suggestions to us
by email. Visit the patient forum today.
Have information on hand before you call
Before calling a treating site, it will
be helpful if you have the following
information available:
Your diagnosis as stated by your
physician.
A list of all previous treatments and
their dates.
Include surgery; types of chemotherapy (chemical and doses); radiation
therapy (record of total dose received);
and the physician and site where you
received them.
Names, addresses and phone numbers of all treating physicians and
institutions. Include endocrine lab
studies within the past six months.
Dates and places where all scans or
angiograms were completed. You
will probably need copies of the
most recent scans.
Current symptoms and problems,
especially those related to memory,
speech and communication, ability
to care for self, work level, personality changes, physical mobility and
mental comprehension.
Health insurance card(s).
A list of all other medical conditions
such as heart or thyroid problems,
diabetes, high blood pressure, etc.
A primary contact person (other
than yourself) with address and
phone number.
Writing all of this information on
paper will enable you to mail or fax it
immediately to a medical professional
or treatment facility.
Another Perspective, Volume 5, Number 1
9
AVM
Continued from page 8
Kevin had indeed suffered a large hemorrhage - from what, doctors couldn’t
tell. They thought it was probably an
aneurysm.
“Maybe it was just mother’s intuition,
but I suspected an AVM,” Beth says.
Because Kevin was so young and his
condition was so serious, he was flown
by helicopter to Children’s Hospital in
Pittsburgh. The family drove there in
their car.
By the time they arrived, Kevin was
already in the operating room getting an
extra-ventricular drain to remove the
blood and decrease the intracranial pressure. Doctors had also done an
angiogram, which showed the hemorrhage (a major stroke) was caused by an
AVM in the basal ganglia - nerve clusters deep within the cerebrum above the
brain stem.
“There was not much hope for Kevin
that night and we were told to prepare
for the worst,” Beth recalls. “The doctors told us he had no brain stem reflexes
on admission.” But overnight, Kevin
started to show some improvement. “To
the amazement of his doctors and nurses,
by the sixth day, he was weaned from
the ventilator,” transferred out of the
intensive care unit and moved to a neurosurgical floor, Beth says.
She knew they had a long road ahead
of them. Kevin’s left side was weak and
he suffered short-term memory loss and
some expressive aphasia (an inability to
express himself verbally) and facial
droop.
However, his mother notes, “We were
just so thankful that he was alive.”
The neurosurgeon told the family that
because of its size and location, the only
way to treat Kevin’s AVM was with
radiosurgery.
The couple met with Dr. Lunsford at
the University of Pittsburgh. He
explained how his radiosurgery machine
worked and what the procedure would
involve. Kevin could not be treated until
most of the blood from the hemorrhage
had been absorbed.
In the meantime, he was transferred
back to his local Hospital for physical
and speech therapies. He had to regain
his sense of balance and learn how to
walk again.
Finally, after being hospitalized for
40 days, Kevin went home. He was still
very weak and had ongoing therapy as
an outpatient.
“Fatigue set in and Dave and I had
frequent little arguments and misunderstandings,” Beth relates. “I was unable
to eat or sleep and lost a lot of weight. I
soon realized I needed to enlist the help
10
Another Perspective, Volume 5, Number 1
of our Mental Health Unit if the family
were to get back on track.”
Kevin was admitted to
Children’s Hospital October 4,
1990, for an MRI and blood
work. He was treated radiosurgically by Dr. Lunsford using the
Gamma Knife the next day.
General anesthesia was used
because he was so young. The
whole procedure took about six
hours, Beth recalls.
“When Kevin came back to
his room, he only suffered
some mild nausea and vomiting.” she says. “He had no
pain or headache” and was
able to go home the next
day.
“We had yearly follow-ups
with Dr. Lunsford, consisting of an MRI
and neurological exam,” Beth says.
“Kevin was doing well,” she adds.
His facial droop had gone away as did
his left side weakness. He was lefthanded prior to the hemorrhage, but was
now using his right hand for most every-
“We are continually faced by great
opportunities brilliantly
disguised as insolvable problems.”
– Lee Iacocca
thing. He was in first grade and doing
all the things any 7-year-old would do”.
But tragedy struck again four years
later. It was a cold winter day and the
boys were playing outside in the snow
with their radio-controlled bulldozer.
Beth told Kevin and Eric not to stay out
too long and promised to make hot
chocolate for them when they came in.
“Kevin was the first to come bounding in the back door, taking off his coat
and yelling, ‘Hot chocolate, Mom!’”
Beth relates. “He sat down at the table
and started to sip his cocoa. I noticed he
was rubbing the back of his neck. He
said, ‘I’ve got a stiff neck, Mom.’”
Fear came over her and Beth’s stomach churned. Kevin started to hold the
back of his head and said he was getting
a headache.
“I knew what was happening but didn’t want to believe it,” Beth says. “I was
nauseated and shaking. I had to quickly
compose myself. I told Dave we were
going to take Kevin over to the emergency room.” As Dave put Kevin’s shoes
on, the boy turned pale and started to
vomit. Beth called out the window for
Eric, telling him Kevin was sick again
and had to be rushed to the hospital.
“Kevin’s level of consciousness was
decreasing rapidly as we sped over to the
hospital,” Beth says. She told the emergency room physician what was wrong.
Kevin was placed on basic
life support and
flown
to
C h i l d r e n ’s
Hospital for
further treatment.
This
time
around, while
Kevin’s neurological condition
s t e a d i l y
improved during
his hospital stay,
he suffered several
infections, including ones affecting
his spinal fluid and
blood.
But Kevin “rallied
through all the adversities,” Beth says,
and
he
was
discharged on his eighth birthday,
March 21, 1994.
Since this was Kevin’s second major
hemorrhage, Dr. Lunsford again consulted with a physician who specialized in
resecting difficult AVMs. However, this
specialist urged the family to pursue further radiosurgery for Kevin instead.
Brain surgery, they were told, would
likely leave Kevin with permanent
deficits, including probable paralysis.
So he was treated a second time with
Gamma Knife in May, 1994.
In October 1996, he had a follow-up
angiogram that showed the AVM had
shrunk and there was “significant reduction” in its blood flow.
Today, Kevin is a healthy, happy 14
year-old who is developing normally
with a residual mild to moderate left side
hemiparesis (muscular weakness or partial paralysis), mildly affecting his arm.
He has undergone two tendon transfers
in his left foot to correct a type of foot
drop he developed after the second hemorrhage and surgery to his left arm. His
Dad says that you can hardly tell there
was a problem with his foot.
Kevin has some mild spatial perception problems as a result of his damage
from his original stroke. This does not
affect his love of computers and music.
He is a great fan of Britney Spears!
While restricted from contact sports, he
still loves fishing and camping. He digs
his own bait and enjoys walking in the
woods.
“We are forever thankful for wonderful doctors and nurses who cared for him
and the technology,” Beth says.
“Without these things, Kevin may not
have had a chance for a normal life.”
His father, Dave, says “he is a great kid,
who is never a behavior problem.”
Acoustic Neuroma
Continued from page 1
Until December 1999! My husband
Jeff experienced a sharp hearing reduction in his right ear and went to his ear,
nose & throat doctor for a check-up. It
wasn’t a cold or stuffed ear, and the
hearing test indicated that an MRI was
required to rule out an acoustic neuroma.
I’ll let Jeff tell the rest of the story.
Jeff:
I was unconcerned about my hearing
loss in the early days. I participated in
Marjie’s discovery of her acoustic neuroma and subsequent search for the appropriate medical solution. The odds of
having an acoustic neuroma are one in
100,000. I had a COLD with a stuffed
ear; the probability of us both having
this tumor were incalculable. I received
the results of the MRI in mid-December:
I had an acoustic neuroma in my right
ear, .8 centimeter by 1.2 cm centimeters.
I remember the fear and concern we
both had when Marjie found out about
her acoustic neuroma. There was so
much we didn’t know, including the wisdom of her decision to choose radiosurgery. This time was very different.
Marjie took control of my medical life. I
received the news approximately
December 20th and Marjie scheduled
my appointment for radiosurgery with
Dr. Lunsford on January 21, 2000.
Actually the month passed in a rather
uneventful manner. There were no questions or uncertainty. We both knew this
was the right decision.
We arrived in Pittsburgh on January
20th for a consultation and I had my
treatment the following morning. The
Gamma Knife team was extraordinarily
professional, reassuring and caring.
Everything went very smoothly and I
was released from the hospital before
noon the day of the surgery. I felt great
and wanted to spend the afternoon sightseeing in Pittsburgh. “Doc” Marjie took
me back to the hotel for an afternoon of
rest, ice packs and bandages. I did not
experience any swelling or headaches,
and on Saturday morning we drove back
to Columbus. Two days later I jogged
five miles and then worked out with
weights.
We are both thankful that we live in a
time in which medical science has
advanced to a point where diseases such
as ours can be discovered and “cured”
without invasive treatment. More
importantly, we look forward to the day
when referring doctors will cast aside
their biases toward surgery and inform
newly diagnosed patients of this spectacular option.
Research in Progress
The following exerts were presented at the 10th International
Meeting of the Leksell Gamma Knife® Surgery Society, April, 2000,
Squaw Valley, California.
Obesity:
Researchers at the University of Virginia treated obesity in rats with Gamma Knife radiosurgery. They irradiated the hypothalamus, which controls body weight, of obese rats.
Rats treated with two doses of 40 Gy experienced significant weight reductions beginning
nine weeks after treatment and lasting until the end of the study, at 34 weeks.
–also presented at the 1999 annual meeting of the Congress of Neurological Surgeons in
Boston, Mass.
Pain:
Researchers at Yale University School of Medicine treated three patients with intractable
pain of benign origin associated with monopolar depression with Gamma Knife radiosurgery. A closed stereotactic cingulotomy was performed on each with doses of 140 Gy
for two patients and 180 Gy for the remaining patient. To date only the patient receiving
180 Gy has benefited from the intervention.
Glaucoma:
Twelve patients were treated with Gamma Knife radiosurgery at the Hospital Na Homolee,
Prague, Czech Republic, for advanced stages of glaucoma (blind or very diminished vision
with pain). All patients received alleviation of ocular pain and the intraocular pressure was
reduced or normalized. There were no early side effects. Dosages in the first group were
28 Gy with 14 Gy to the 50% isodose, and for the second group 40 Gy with 20 Gy to the
50% isodose curve.
another
perspective
Volume 5, Number 1
T
he International Radiosurgery Support
Association is an independent organization dedicated to providing information
through personal contact and educational
materials, encouraging research and promoting patient options about radiosurgery
treatment and its availability.
❦ Rebecca L. Emerick
Managing Director
❦ Tonya K. Ledbetter
Editor
❦ Tomasz Helenowski
Medical-Technical Advisor
Chicago, IL USA
Contributing Authors and Medical Advisors:
❦ Alan Appley
Orlando, FL USA
❦ Edward R. Laws Jr.
Charlottesville, Virginia, USA
❦ Ronald Brisman
New York, NY USA
❦ Christer Lindquist
London, England UK
❦ Lawrence Chin
Baltimore, MD USA
❦ L. Dade Lunsford
Pittsburgh, PA USA
❦ Christopher Duma
Newport Beach, CA USA
❦ Georg Norén
Providence, RI USA
❦ Michael S. Edwards
Sacramento, CA USA
❦ Maheep Singh Gaur
New Delhi, India
❦ Deane Jacques
Los Angeles, CA USA
❦ Jonathan Knisely
New Haven, CT USA
❦ Douglas Kondziolka
Pittsburgh, PA USA
❦ Kenneth Ott
La Jolla, CA USA
❦ Swaid N. Swaid
Birmingham, AL USA
❦ Harish Thakrar
Chicago, IL USA
❦ Aizik L. Wolf
Coral Gables, FL USA
❦ Ronald Young
Los Angeles, CA USA
Seattle, WA USA
ANOTHER PERSPECTIVE (ISSN 1086427X), IRSA’s support publication, is
published quarterly by the International
Radiosurgery Support Association. Business
office located in Harrisburg, PA. Contents copyright 2000 by IRSA. All rights reserved. Call
(+717) 671-1701 for subscription information.
Disclaimer
This publication is not intended as a
substitute for professional medical advice
and does not address specific treatments
or conditions specific to any patient. All
health and treatment decisions must be
made in consultation with your
physician(s), utilizing your specific
medical information.
Another Perspective, Volume 5, Number 1
11
More About MRIs
An MRI (magnetic resonance imaging) is a diagnostic technique that allows
us to look inside the body without using
X-rays. The pictures are so precise that
doctors can often get as much information from an MRI as they would from
looking directly at the brain tissue itself.
A large magnet, radio waves and a
computer are used to make the MRI pictures. The magnet creates a strong,
steady magnetic field that causes the
body’s protons, which normally spin randomly, to line up together and spin in the
same direction.
A radio frequency signal is beamed
into the magnetic field. The signal
makes the protons move out of alignment. When it stops, the protons fall
back into their aligned position and
release energy. A receiver measures the
energy released by the disturbed protons
and the time it takes for them to return to
their aligned position with the magnet.
These measurements indicate the type of
tissue that’s been scanned and its condition. The computer takes this information and constructs an image on a TV
screen. These images can be recorded on
film or magnetic tape for a permanent
record.
Unlike X-rays, the magnetic fields
used in an MRI aren’t known to be
harmful to us. We do not know if there
are short or long-term side effects at this
time.
During the scanning, you may hear
some loud thumping sounds. With newer
MRI equipment, there is only a very
minor sound and you can watch videos
or listen to music. Credit cards and
watches should not be taken into the
scanner as information will be erased
and batteries drained.
The MRI scans through bone while
clearly defining soft tissue. The images
are especially valuable for diagnosis of
tumors, abnormal fluid, stroke, cancer
and traumatic injuries. While there is a
large “bore” MRI available for those
who do not like small places, technicians
say the small “bore” gives the best defin-
ition and clear outline when looking at
brain tumors and lesions. Contrast agents
(dyes) make many tumors and lesions
even clearer.
For the best results with your disorder, always schedule your MRI as
requested by your doctor. Early detection
of changes in any condition are vital to
early treatment and eventual survival.
Editor’s note: On a molecular level, all things
– people, plants, rocks, etc. – are composed of
atoms. These in turn include even tinier particles
such as protons.
Here are questions to ask
when seeking treatment
The Association encourages patients
seeking treatment to ask the following questions:
Will a neurosurgeon direct my
treating team?
Does this facility use radiosurgery to treat at least 75
patients for brain tumors and
disorders annually?
Has your equipment been modified in its targeting ability since
it was manufactured?
Are you a participating member
of the International Radiosurgery
Support Association?
International Radiosurgery Support Association
Delivery: 3540 N. Progress, S. 207, Harrisburg, PA 17110 USA
Mailing: P.O. Box 60950, Harrisburg, PA 17106-0950 USA
Phone: +(717) 671-1701 Fax: +(717) 671-1703
ADDRESS SERVICE REQUESTED
Internet: www.irsa.org
Email: [email protected]